DRAFT: This module has unpublished changes.
DRAFT: This module has unpublished changes.

Janine Logan  MetHC750   Final Project   April 26, 2016

Closing the Gap in Cardiovascular Disease Risk

Target Group

    The adult Hispanic population in Tennessee shows a marked disparity when it comes to cardiovascular disease risk and treatment.  Certainly one contributing factor is the disproportionately high rate of poverty among this population compared to other ethnicities in the state and the broader U.S. population.  Forty-one percent of the adult Hispanic population lives in poverty, which is nearly double the national rate of 24 percent.  And even compared to the adult Black population and the Hispanic population, the rate is 26 percent vs. 41 percent, respectively.[1]  Other reasons point to cultural sensitivities and poor diet and exercise habits.

Selected Health Indicators

  • Physical activity 
  • Nutritional status
  • Health literacy

     These broad indicators will be considered along with income and insurance status, since these two indicators influence most other socioeconomic issues, including education, housing, employment, and food affordability. 

Barriers

     Hispanics’ access to routine health care services is hampered by the fact that this ethnic group has a much higher rate of no insurance compared to the rest of the Tennessee adult population.  This is complicated by Tennessee’s decision to not expand Medicaid under the Affordable Care Act.  Given the severe poverty prevalent among this ethnic group, cost of care is a significant barrier.  Overall, 16 percent of Tennessee’s adult residents went without needed care due to cost in the past year, as compared to the United States average of 14 percent[2].  That contrasts with the Agency for Healthcare Research and Quality’s (AHRQ) benchmark comparisons that place the state 523% away from reaching the achievable benchmark of Hispanic adults who needed to see a physician within the past 12 months but could not because of cost.[3]

     As a republican state, it is unlikely that Tennessee will move any time soon to expand Medicaid.  However, Tennessee’s Department of Health is actively pursuing a population health improvement program.  Although the plan is mainly focused on moving Tennessee’s health care system to a value-based payment one, there is a requirement that some of the monies from the federal Centers for Medicare and Medicaid Services State Innovation Model grant be used to address prevention, health equity, health behaviors, and the influence of social determinants of health.[4]

     In addition to language barriers faced by many Hispanics, their cultural beliefs about health and healing also affect access to care.  Some hold fast to alternative therapies that may involve herbs and other non-traditional home remedy treatments.  Religious beliefs and the emphasis on family, as well as the importance of warmth in relationships, are all subtle factors that influence Hispanics’ interaction or lack of interaction with health care providers.[5] [6]

Cardiovascular Disease Prevalence

     According to benchmark data from AHRQ, Tennessee’s Hispanic population is far from meeting national benchmarks, specifically in the area of blood pressure control and affordable access to health care.[7]  Poorly managed blood pressure, inactivity, and poor nutritional habits are predictors of future cardiovascular disease that can manifest itself in a variety of ways – stroke, heart attack, and heart failure.  In a study about heart pumping ability appearing in the Journal Circulation, researchers found that Hispanics are particularly vulnerable to heart pumping problems because they are more likely than other races in the population to have risk factors for heart failure, such as high blood pressure.[8] 

     What can be done to help adult Hispanics in Tennessee obtain equal access to routine care that will help the adult population decrease its risk for cardiovascular disease?  As uncontrolled blood pressure is an indicator for more serious and acute cardiovascular diseases, it makes sense to begin with strategies aimed at making access to blood pressure screenings convenient, affordable, and regular.  Concurrently, these strategies provide an opportunity for education at every encounter aimed at teaching the target group the importance of healthy lifestyle behavior and choices, which will help them control blood pressure.  Not only will these efforts lead to better care and a better quality of life for the patient, but averting acute illness episodes will save money for the state’s health care system in the long run. 

Objectives

1. At the conclusion of two years, increase the percentage of adult Hispanics who engage in leisure time physical activity by 10 percent.

Baseline: Center for Disease Control and Prevention State Indicator Report Physical Activity 2010

2. At the conclusion of two years, increase by 10 percent the number of adult Hispanics who can recall their most recent blood pressure reading.

Baseline: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 1998 – 2012.

3. At the conclusion of two years, reduce avoidable admissions for hypertension per 100,000 of the Hispanic adult population from 32.9 to 30.9.

Baseline: Agency for Healthcare Quality and Research, National Healthcare Quality and Disparities Report, Tennessee Hispanic Quality Measures Compared to Achievable Benchmarks,

 2014

Strategies

1. Increase access to places to exercise        

            Work with local public school districts to hold open gym nights twice weekly, as well as provide access to tracks and fields.  Schools provide a convenient location for exercise and adults may be enticed to participate because of the familial nature of school-based exercise locations. Educational materials will be distributed that are appropriately health literate.  Funding would be shared between state and local health county health departments and the local school districts.

2. Increase access to regular blood pressure measurement

            Work with local fire departments (city, suburban, rural) to hold blood pressure screening events once each month at the neighborhood fire houses, perhaps on a Saturday or Sunday. Utilize services of fire department emergency medical technicians and/or practical nurses from local health departments to measure residents’ blood pressures.  This strategy places the health services in the heart of the community and offers residents a convenient and accessible way to track their blood pressure.  Encourage monthly return visits.  Educational materials will be distributed that are appropriately health literate.  Strategy jointly funded and staffed by local health departments and local fire departments.    

3. Encourage healthy eating habits

            Establish Salt Free Zones at local eating establishments and school cafeterias.  Remove all salt shakers from tables and counters and only provide a shaker upon request.  Restaurant owners, chain establishments and independents, would sign a Salt Free Zone pledge. Educational materials will be distributed that are appropriately health literate.   Costs are minimal and can be absorbed by the state health department and/or the state could seek grant funding from local, state, or federal healthy food options initiatives.

Awareness Campaign

     Unless the targeted population knows about these opportunities to improve health and understands why adopting healthier behaviors is necessary, efforts are in vain.  A suggested theme for the campaign is “Your Numbers Matter.”  And given the population’s limited English proficiency, all print and broadcast materials will be available in English and Spanish, as well as adhere to the principles of clear communication[9] and be sensitive to cultural norms of the population.   An integrated communications/marketing campaign is proposed.   The campaign will rely heavily on social media and mobile media/marketing.  Studies have shown that those of lower socioeconomic status and who are minorities are more likely to be smartphone owners and are less likely to rely on home television and cable access for news and information.[10]

Campaign Goals

  • Raise awareness about importance of blood pressure screening, knowing your numbers. 
  • Provide education about health consequences of uncontrolled blood pressure.
  • Inform targeted population about interventions.

Campaign Components

   Collateral Print Materials

     These will be key to success, as posters, flyers, point-of-purchase materials, table top tent cards and the like will be distributed within communities at local libraries, civic centers, churches, fire houses, local businesses, health centers, hospitals, physician offices and among community-based organizations.

   Public Relations Tactics

     These include traditional tools, such as news and feature releases, sent to local print publications, web-based news outlets, public affairs programs, and local radio and television outlets.  The hope is to secure earned media placements. 

   Digital Marketing and Advertising 

    This will include purchase of mobile ads on Facebook, as well as timed series of posts on Facebook and Twitter.  Ads will also be purchased on websites that are frequently viewed by the target population.   Websites sponsored by local health departments and all community partners will be encouraged to display information about the awareness campaign and interventions on their sites.  These sites will link to the state’s department of health website where full information about the campaign, intervention efforts, and all educational components will reside.  


[1] Kaiser Family Foundation website, State Health Facts. Accessed April 23, 2016 http://kff.org/state-category/demographics-and-the-economy/      

[3]U.S Department of Health and Human Services, Agency for Healthcare Research and Quality, National Healthcare Quality and Disparities Reports. Accessed April 23, 2016.  http://nhqrnet.ahrq.gov/inhqrdr/Tennessee/benchmark/table/Priority_Populations/Hispanic#far

[4] Tennessee Department of Health.  Accessed April 23, 2016. https://www.tn.gov/health/article/health-planning-announcements

[5] Medina, Claudia. “Belief and Traditions that Impact the Latino Healthcare.” New Orleans: LA: LSU School of Public Health. PowerPoint.  Accessed April 23, 2016.  http://www.medschool.lsuhsc.edu/physiology/docs/Belief%20and%20Traditions%20that%20impact%20the%20Latino%20Healthcare.pdf

[6] Poma, Pedro A. “Hispanic Cultural Influences on Medical Practice.” Journal of the National Medical Association 75.10 (1983): 941–946. Print.

[7] U.S. Department of Health and Human, Agency for Healthcare Research and Quality, National Healthcare Quality and Disparities Reports.  Accessed April 23, 2016.  http://nhqrnet.ahrq.gov/inhqrdr/Tennessee/benchmark/table/Priority_Populations/Hispanic#far 

[8] Mehta, Hardik et al. “Burden of systolic and diastolic left ventricular dysfunction among Hispanics in the United States – Insights from the echocardiographic study of Latinos.” Journal Circulation. 2015; 1 32:A19878.

[9] U.S. Department of Health and Human Services. Clear and Simple. Bethesda, MD. National Institutes of Health.    

[10]Smith, Aaron. Pew Research Center. “U.S. smartphone use in 2015.” April 1, 2015. Accessed April 23, 2016  http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/

 

Evaluation Plan*

 

Indicator: Physical Activity

Objective

Strategy

Process Measures

Timeline

Outcome Measures

Increase percentage of physical activity

Open Gyms

Number of participating gyms

At start, then every 3 months

Change in total number of gyms participating

 

 

Number of adults signing in

Each open gym night

Change in total number of adults participating

 

 

Number educational flyers distributed

At start, then every 3 months

Frequency of distribution

 

 

Physical activity knowledge

At start and then conclusion via random telephone surveys

Number in target group who achieved knowledge link between physical activity and its effect on blood pressure

 

Indicator: Nutrition

Objective

Strategy

Process Measures

Timeline

Outcome Measures

Reduce avoidable hospital admissions due to hypertension

Salt Free Zones

Number of eating establishments participating

At start, then every 3 months

Participation level

 

 

Number of times salt shaker requested

At start, then every 3 months

Frequency of requests

 

 

Number of educational flyers distributed

At start, then every 3 months

Frequency of distribution

 

 

Number of hospital admissions due to hypertension

At start, then every 3 months

Number change in admissions

 

 

Nutritional knowledge

At start and then conclusion via random telephone surveys

Number in target group who achieved knowledge link between salt intake and related dietary matters affecting blood pressure

 

Indicator: Health Literacy

Objective

Strategy

Process Measures

Timeline

Outcome Measures

Increase knowledge about and access to blood pressure screenings

Community-based,  local blood pressure screenings

Number firehouses participating

At start, then every 3 months

Participation level

 

 

Number of adults signing in

Each screening event

Number of adults with BP measured

 

 

Number of educational flyers distributed

Each screening event

 

 

 

Healthy behaviors knowledge

At start and then conclusion via random telephone surveys

Number in target group who achieved knowledge link about adoption of healthier behaviors and cardiovascular disease risk

 

*Plan assumes overlap. Indicators, strategies, and measures are all interdependent and work together to improve health and reduce risk and incidence of cardiovascular disease for the target group.

 

Tennessee Health Status: SWOT Analysis

 

Strengths

Weaknesses

No state deficit

Has plan for population health

Higher than U.S. average for older adults

   getting recommended preventive care

One of four states in bottom quartile to

   improve on the greatest number of

   performance indicators

Significantly more RNs and NPs per 100,000

   of population compared to U.S.

Generous hospital bed capacity

Ample state parks

 

No expansion of Medicaid

Pockets of high poverty – Hispanics highest

   among all ethnicities in the state

Hispanics highest rate of state’s uninsured at

   31 percent; 10 percent above U.S. average

   for this population

Compared to U.S. average:

    Lower life expectancy for men/women

    Higher percentage adults report poor or fair

      health status

    Adult and children exceed percent obese

      and overweight by 3 percent categorically

Black infant mortality rate very high

   compared to other ethnicities in state

Insufficient healthy food retailers per census

   tract compared to U.S.

Adults lag in physical activity compared to

    U.S.

Opportunities

Threats

Population health improvement plan

Develop more user friendly, interactive

   website for state health department

Right size bed capacity for efficiency

Adult daily fruit/vegetable intake sufficient,

    but room for improvement

Increase public places to exercise

Apply for Center for Medicare Medicaid

   Innovation Center grant (primary care)

Optimize RN and NP workforce

Possible repeal of ACA

Political resistance on local and state levels

High poverty rate

Funding cuts for social supports

Tables reviewed for SWOT:

http://www.commonwealthfund.org/publications/fund-reports/2015/dec/aiming-higher-2015

http://www.commonwealthfund.org/interactives-and-data/estimated-impact-interactive#?ind=a_Adults_who_went_without_care_because_of_cost_in_the_past_year_2015&loc=TN

http://www.commonwealthfund.org/interactives-and-data/estimated-impact-interactive#?ind=q_Older_adults_with_recommended_preventive_care_2015&loc=TN

http://www.cdc.gov/nutrition/downloads/state-indicator-report-fruits-vegetables-2013.pdf

http://www.cdc.gov/physicalactivity/downloads/PA_State_Indicator_Re

http://kff.org/state-category/demographics-and-the-economy/

http://kff.org/state-category/minority-health/

http://kff.org/state-category/providers-service-use/

https://innovation.cms.gov/initiatives/map/index.html#state=TN&model=comprehensive-primary-care-initiative

 

 

 Bibliography

 

American Hospital Association. Equity of Care: A Toolkit for Eliminating Health Care Disparities. Chicago, IL: American Hospital Association. January 2015. Print.

Bahls, C. “Health Policy Brief: Achieving Equity in Health.” Health Affairs. October 6, 2011. Print.

Commonwealth Fund website. Interactive Data. Accessed 23, 2016 http://www.commonwealthfund.org/interactives-and-data/estimated-impact-interactive#?ind=a_Adults_who_went_without_care_because_of_cost_in_the_past_year_2015&loc=TN

Freiden, T. “A Framework for Public Health Action: The Health Impact Pyramid.” American Journal of Public Health. 100.4 (2010). Print.

Juckett, G. “Caring for Latino Patients.” American Family Physician. 2013 January 1:87(1):48-54. Print.

Kaiser Family Foundation website, State Health Facts. Accessed April 23, 2016 http://kff.org/state-category/demographics-and-the-economy/     

Lukoschek, P. et al. “Patient and Physician Factors Predict Patient’s Comprehension of Health Information.” Patient Education and Counseling. 50 (2003): 209. Print.

Medina, Claudia. “Belief and Traditions that Impact the Latino Healthcare.” New Orleans: LA: LSU School of Public Health. PowerPoint.  Accessed April 23, 2016.  http://www.medschool.lsuhsc.edu/physiology/docs/Belief%20and%20Traditions%20that%20impact%20the%20Latino%20Healthcare.pdf

Mehta, Hardik et al. “Burden of systolic and diastolic left ventricular dysfunction among Hispanics in the United States – Insights from the echocardiographic study of Latinos.” Journal Circulation. 2015; 1 32:A19878.

Poma, Pedro A. “Hispanic Cultural Influences on Medical Practice.” Journal of the National Medical Association 75.10 (1983): 941–946. Print.

Schroeder, A. “We Can Do Better – Improving the Health of the American People.” New England Journal of Medicine. 357:1221-8. (2007). Print.

Shiavo, R. Health Communication from Theory to Practice. 2nd ed. San Francisco, CA: Jossey-Bass, 2014.  Print.

Smith, Aaron. Pew Research Center. “U.S. smartphone use in 2015.” April 1, 2015. Accessed April 23, 2016  http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/   

Tennessee Department of Health.  Accessed April 23, 2016. https://www.tn.gov/health/article/health-planning-announcements

U.S Department of Health and Human Services, Agency for Healthcare Research and Quality, National Healthcare Quality and Disparities Reports. Accessed April 23, 2016.  http://nhqrnet.ahrq.gov/inhqrdr/Tennessee/benchmark/table/Priority_Populations/Hispanic#far

U.S. Department of Health and Human, Agency for Healthcare Research and Quality, National Healthcare Quality and Disparities Reports.  Accessed April 23, 2016.  http://nhqrnet.ahrq.gov/inhqrdr/Tennessee/benchmark/table/Priority_Populations/Hispanic#far 

U.S. Department of Health and Human Services. Clear and Simple. Bethesda, MD. National Institutes of Health.    

Wagner, K. Activating Patient Engagement for Population Health. Healthcare Financial Management Association Leadership. Winter 2016: 41-45. Print.

 

luttges_powerpointfinalproject_loganjanine.pptx   

 

 

 

DRAFT: This module has unpublished changes.